Top Mistakes in Medical Credentialing That Can Cause Revenue Loss

One of the primary fundamentals of the healthcare industry in the United States is to maintain standards that make quality medical care accessible. But like every other sector, the healthcare industry also faces uncertain demand and ever-growing challenges. The fact remains that there is never room for treatment errors while the cost has to stay optimistic. These are some primary reasons why medical credentialing became vital.

Medical credentialing is much like a quality assertion process among providers, which helps reduce medical errors. The process involves an in-depth verification of the educational qualifications, experience, licensure, training background, and much more. Credentialing is necessary before the provider can join on-ground procedures in a healthcare facility or while adopting a new insurance provider.

What does credentialing include:

• Medical Credentialing: This involves verifying qualifications, career background, and practicing licenses before consultations commence.
• Privileging: It involves getting sanctions to perform specific treatments or procedures.
• Enrolment: This includes getting credentialed by insurance companies to enlist in their panel. It is followed by contract negotiations that enable reimbursements and payments.

Who needs to get credentialed?

All medical professionals must get credentialed, including doctors, nurses, dentists, chiropractors, physical therapists, podiatrists, optometrists, physician assistants, and mental/behavioral health practitioners. Additionally, hospice care, hospitals, clinics, surgery centers, diagnostic centers, labs, ambulance services, and sleep research clinics must be certified.

Credentialing mistakes that can cost you

Credentialing is undoubtedly one of the complex and time-consuming processes. Doing it wrong can cost you a lot of resources and money. In addition, any mistake with the credentialing process will throw the entire process for a toss, creating legal implications.

2. Errors with timing and planning

Credentialing involves an enormous amount of data. The data used is vital, and it will take at least 3-4 months on an individual level to complete the process. Getting credentialed, collecting, and preparing the required documents will take the longest. 

For a provider, the delay means you cannot get started. You must wait until the process is over to start consulting patients and rendering your services. Insurance companies will not reimburse if a new provider is taken on board. Improper planning of medical credentialing can make the wait longer.

• Data entry errors

If your application lacks accuracy, you have a reason for denial on the table. Some of the most common errors regarding that are:

• Typing errors

Mistakes that happen during data entry are common. Providers need to recheck the data entries to avoid such mishappenings. Misspelled titles, wrong email addresses, inaccurate postal addresses, wrong NPI numbers, and incorrect identification/license numbers can quickly derail the entire process.

• Missing information.

One of the most common credentialing errors to avoid while manually preparing the documents is the absence of important information or entirely omitting a required document.

• Unorganized documentation

Poor document handling and arrangement cause uncertainty and confusion throughout the application process, necessitating frequent resubmission.

2. Compliance Errors

Each state in the United States has different credentialing requirements, and providers or assistance staff often fail to comply. 

• Inexperienced staff:

Sometimes due to sheer ignorance about the insurance carrier’s requirements, the clinic employees who are given the task of credentialing ball up everything. It takes a good amount of training to do things properly.

• Non-compliance with standard regulations

For credentialing and enrollment processes, every insurance company has distinct requirements that are to be completed. If the specifications are not met, the payment process gets delayed, hampering financial strength.

• Unaware of specialty specifics 

In addition to other problems with the medical billing process, lack of competence in credentialing or privileging for specialty practices extends to both. Therefore, in addition to the usual requirements, specific documentation demonstrating proficiency in the specialty practice will be required during credentialing.

• Unaware of legal implications

The clinical staff assigned to the credentialing process may be unaware of the legal ramifications of the current application. Although a layman’s limited understanding of legal language is understandable, the practice may be subject to legal liability if things are not in order.

3. Errors in Enrolling process.

Billing and payment are intimately connected to the enrollment procedure. Therefore, any faults in this area could affect how the healthcare revenue cycle management is handled. Let’s examine the common errors that occur during the enrollment procedures.

• Skipping insurance provider criteria

Every insurance carrier has unique guidelines for adding new providers to its panel, including deadlines, procedures, and rules. Unfortunately, a common mistake in medical credentialing is not keeping up with the provider’s requirements.

• Unaware of insurance companies

Every insurance company has different requirements for adding new providers to its panel, including dates, procedures, and criteria. Not satisfying the provider requirements is an error that frequently happens in medical credentialing.

• Not having dedicated staff to answer.

Insurance companies may have several questions, clarifications, and primary source verifications before enrollment. It hampers the payment procedure if the facility personnel is not given the proper responsibilities to handle these inquiries for you.

• Revenue Loss

Before enrollment, insurance companies could have a variety of queries, clarifications, and primary source checks. If the facility staff is not given the required responsibilities to handle these inquiries for you, it could delay the entire process.

4. Lack of Expert Support

Even remotely associated with the healthcare industry, one would know that medical billing and credentialing services are elixirs that keep practices financially sound. But unfortunately, in the past few years, insurance credentialing services have become more complex but not impossible.

Many things could go wrong if you try to conduct the credentialing internally at your practice, so it might not be such a brilliant idea after all. Making the personnel deal with time-consuming, massive paperwork robs them of the valuable time meant for patient care. They lack the skills and experience necessary to meet the process’s standards, which could cost you a lot of money.

Capline Healthcare Management can assist you in striking a balance between managing the business and taking care of administrative tasks like credentialing. If you want to run a hassle-free and successful long-term practice, get accredited with the help of the best-rated healthcare assistance company in the United States.